Management of Anticoagulation during Extracorporeal Membrane Oxygenation in Children

Abstract

Extracorporeal Membrane Oxygenation (ECMO) is often used in critically ill children with severe cardiopulmonary failure. Worldwide, about 3600 children are supported by ECMO each year, with an increase of 10% in cases per year. Although anticoagulation is necessary to prevent circuit thrombosis during ECMO support, bleeding and thrombosis are associated with significantly increased mortality risk. In addition, maintaining balanced hemostasis is a challenging task during ECMO support. While heparin is a standard anticoagulation therapy in ECMO, recently, newer anticoagulant agents are also in use. Currently, there is a wide variation in anticoagulation management and diagnostic monitoring in children receiving ECMO. This review intends to describe the pathophysiology of coagulation during ECMO support, review of literature on current and newer anticoagulant agents, and outline various diagnostic tests used for anticoagulation monitoring. We will also discuss knowledge gaps and future areas of research.

Clinical application of regional citrate anticoagulation for membrane-based therapeutic plasma exchange in children with liver failure

“…The coagulation function of these patients improves gradually as FFP is exchanged, making it more challenging to adjust the heparin dose to maintain the desired integration target. The primary benefit of RCA is its ability to maintain effective anticoagulation in the extracorporeal circulation while having a minimal effect on coagulation in vivo ( 23 ). The commonly used RCA target in clinical practice is an in-vitro iCa concentration of 0.2–0.4 mmol/L ( 24 – 28 ).…”

Pharmacokinetic Modeling Using Real‐World Data to Optimize Unfractionated Heparin Dosing in Pediatric Patients on Extracorporeal Membrane Oxygenation and Evaluate Target Achievement–Clinical Outcomes Relationship

“…6 Patients on ECMO usually receive a UFH bolus dose of 50-100 IU/kg followed by a starting infusion ranging from 20 to 50 IU/h/kg where the younger pediatric patients tend to receive higher starting infusions compared to older ones. 7 Therapeutic monitoring of UFH anticoagulation is usually done through anti-factor Xa, a surrogate marker for UFH exposure, in addition to other coagulation markers such as activated clotting time. 8 Further UFH dose modifications and titrations are usually performed on the basis of the anti-factor Xa levels to reach the therapeutic target of 0.3-0.7 IU/mL.…”

“…Since UFH is considered a polar and charged compound, distribution is restricted to the intravascular space 6 . Patients on ECMO usually receive a UFH bolus dose of 50‐100 IU/kg followed by a starting infusion ranging from 20 to 50 IU/h/kg where the younger pediatric patients tend to receive higher starting infusions compared to older ones 7 . Therapeutic monitoring of UFH anticoagulation is usually done through anti–factor Xa, a surrogate marker for UFH exposure, in addition to other coagulation markers such as activated clotting time 8 .…”